Patient Blood Management in Elective Surgery

1. Preoperative detection of anemia
    1. Risk assessment
      1. The transfusion risk should be assessed prior to surgery and be supported by the use of validated clinical scores when available (e.g. TRUST (cardiac) and TRS (liver))
    2. Anemia assessment
      1. Pre-operative anemia should be assessed, by conducting a complete blood count, at the patient’s initial surgical consultation to avoid unnecessary delay and allow correction if appropriate.
      2. In patients with anemia (hemoglobin 130g/L), assessment should also include serum ferritin, transferrin saturation (if ferritin >30 ug/L), vitamin B12, and creatinine.
      3. Anemia work-up should be considered at the time of the initial surgical consultation to avoid the need for patients to return for further blood samples.
      4. If surgery is urgent, the time available prior to surgery should be used to assess anemia and initiate treatment if necessary.
      5. Non-urgent surgery should be deferred until anemia is investigated and corrected.
  2. Pre-operative transfusion practice
    1. For patients with low pre-operative Hgb, RBC transfusions should be avoided. If considered, RBC transfusion should be ordered only if:

      ● Clear signs/symptoms of impaired tissue oxygen delivery (e.g. pre syncope, shortness of breath, chest pain) AND Hgb ≤90 g/L

      ● Patient is within 48 hours of surgical date, AND surgery cannot be delayed, AND: Hgb ≤70 g/L; Hgb ≤80 g/L for patient with underlying cardiac disease

  3. Erythropoiesis stimulating agents
    1. Erythropoiesis stimulating agents (ESAs) should not be used routinely, except in patients who refuse blood transfusions or have rare blood needs (e.g. complex alloimmunization).

      ● If ESAs are used, they should be administered with iron supplementation.

2. Preoperative treatment of anemia
    1. Patient Blood Management Program
      1. If the hemoglobin level is <130g/L, patients should be referred to the Patient Blood Management program if available at the institution
      2. If the hemoglobin level is 130g/L , patients undergoing targeted procedures should be referred to local ONTraC (Ontario Transfusion Coordinator program) program
    2. Iron supplementation
      1. If hemoglobin ≤130g/L, oral iron supplementation should be prescribed prior to surgery. Initiate Ferrous fumarate 300 mg PO BID on an empty stomach with Vitamin C (500 mg)

        ● Contraindications to iron supplementation: history of hemochromatosis or iron overload

      2. If time to surgery is short, or the patient is intolerant or unresponsive to oral iron, intravenous iron should be considered for patients with an iron deficiency anemia.
      3. Re-evaluate Hgb within 7 days of surgery to ensure a current hemoglobin is available for the clinical team on the day of surgery.
    3. Pre-operative transfusion practice
      1. RBC transfusions should be ordered only if:

        ● signs/symptoms of impaired tissue oxygen delivery (e.g. pre syncope, shortness of breath, chest pain) AND Hgb ≤90 g/L are present

        ● patient is within 48 hours of surgical date, AND surgery cannot be delayed, AND: Hgb is ≤70 g/L or Hgb is ≤80 g/L in patients with underlying cardiac disease

        ● If iron deficiency is also present, patients should receive intravenous iron before or after transfusion

    4. Erythropoiesis stimulating agents
      1. Erythropoiesis stimulating agents (ESAs) should not be used routinely
      2. 2ESAs should be used only for specific indications, including:

        ● Patients who refuse blood transfusions or have rare blood needs (e.g. complex alloimmunization).

        ● Anemia of chronic inflammation

        ● Iron deficiency anemia unresponsive to iron therapy

      3. Use of ESAs should be discussed with PBM clinics.
      4. If ESAs are used, they should be administered with iron supplementation.
    5. Autologous blood donation
      1. Pre-operative autologous blood donation should not be used routinely, except in patients with rare blood needs (e.g. complex alloimmunization).
3. Reduction of surgical blood loss
    1. Cell-salvage
      1. Cell-salvage should only be used intra-operatively if:

        ● Anticipated blood loss >20%

        ● Transfusion rate for the intended procedure is >10%

      2. Contraindications to cell-saver: use of solutions creating RBC lysis (sterile water, hydrogen peroxide, alcohol, hypotonic solution), clotting agents (e.g. surgical, gelfoam), or methylmethacrylate, hematologic disorders (sickle cell disease), and presence of contaminants (e.g. urine, bone chips, bowel content, amniotic fluid). Malignancy is not an absolute contraindication.
    2. Prevention of blood loss
      1. Repetitive phlebotomies should be avoided in patients who are clinically well and have stable laboratory values. In order to minimize iatrogenic blood loss, restrictive ordering practices and use of low volume phlebotomy vacutainers should be used.
      2. Patients should be monitored closely for post-operative bleeding to allow for early identification and management in order to minimize blood loss.
4. Use of Transfusions during Elective Surgery
    1. In the absence of active bleeding and if hemodynamically stable during or after surgery, RBC transfusions should be administered according to the following indications:

      ● Hgb ≤60 g/L: Transfusion is recommended.

      ● Hgb ≤70 g/L: Transfusion is likely appropriate (younger fit patients may tolerate lower Hb, e.g. Hb <60 g/L)

      ● Hgb ≤80 g/L: Transfusion is likely appropriate if signs or symptoms of impaired tissue oxygen delivery (dizziness when standing, shortness of breath, chest pain) or patients has documented history of coronary artery disease

      ● Hgb >90 g/L: Transfusion is not indicated

    2. RBC transfusions should be ordered one unit at a time (after the transfusion, the patient should be reassessed prior to a second transfusion)
    3. After a RBC transfusion, symptoms, signs, and Hgb should be assessed prior to ordering additional units
      1. Signs and symptoms should be reassessed within one hour of the transfusion (including assessment of vital signs and rate of blood loss in case of bleeding)
      2. Repeat Hgb measurement should be obtained

        ● 1 hour after transfusion if active symptoms persist (including bleeding)

        ● The next day (with routine bloodwork), in the absence of active symptoms

    4. When ordering post-operative RBC transfusion, indicate infusion time and precise use of diuretic prior to transfusion, to avoid transfusion-associated circulatory overload (TACO):
      Infusion Time Diuretic
      Low risk of TACO 2 hours No
      High risk of TACO (> 70 years old, active fluid overload+, history of congestive heart failure, renal dysfunction) 4 hours Yes, prior to transfusion
      + TACO: pulmonary edema due to excess transfusion product volume. Clinical presentation includes dyspnea, cyanosis, congestive heart failure, tachycardia, and/or evidence of bilateral infiltrates or enlarged cardiac silhouette on chest x-ray.
    5. Intra-venous iron should be administered in post-operative hemodynamically stable asymptomatic patients with hemoglobin 70-120 g/L.
5. Use of tranexamic acid (TXA) during elective surgery
    1. TXA should be used in selected procedures including:

      ● Elective orthopedic procedures (primary and revision hip and knee replacement; hip fracture)

      ● Elective cardiac procedures

      1. There is insufficient evidence to recommend for or against the routine use of intravenous TXA in patients with additional risk factors for VTE beyond the joint replacement surgery itself. Use of TXA for those patients should be discussed by the surgeon and anaesthesiologist
    2. TXA route of administration (intra-venous, oral, or topical) should be left at the discretion of the surgeon and anaesthesiologist.
    3. There is insufficient evidence to recommend one specific dose of TXA over another. In the absence of a different preferred dose, surgeons and anesthetists can consider the following doses
      1. For intra-venous administration: TXA should be given to patients prior to the skin incision with a single weight-based IV dose of 20 mg/kg.
      2. For oral administration: TXA should be given as 2g PO 2 hours prior to surgery.
      3. For topical administration: TXA should be used with 1.5g either injected into the joint after capsule closure or bathed into the joint for minimum 3 minutes prior to closure.